Last week three mothers shared their motherhood journeys. They were as diverse as can be from a home birth to a surprise pregnancy that changed everything and a comparison of what it’s like to give birth in a country with one of the most advanced healthcare systems.
Regardless of the circumstances, bringing a child to this world comes with a unique set of challenges. And we thought, “why not ask the experts” some follow-up questions and provide a wholesome second article on what women need to know about antenatal care, especially, if it’s a first pregnancy.
If you are a first-time mom, what challenges should you expect, what are your priorities and what do experts think about emerging trends in antenatal care?
About “Doctor Google” ...
For five years, Riziki Dama, worked as a nurse, every so often engaging mothers and their children. It is during these engagements that she realised a lot of health issues were tied to what people ate.
She went back to school to study nutrition because she wanted to help patients take a preventive approach when it comes to their antenatal and early childhood care.
She currently specialises in the maternal child health clinic (MCH) where she deals with pregnant mothers on a day-to-day basis and children immunisation. Dama says the first and most common challenge women face is dealing with myths. The minute you announce to friends and family that you are carrying a precious little one, you get a lot of unsolicited advice on how to eat and a never-ending list of dos and don'ts. Then there is the internet.
“Most mothers are convinced to eat a lot because they are ‘eating for two’. Some of them will increase their intake to five proper meals a day and this increases the risk of obesity, high blood pressure and diabetes (if they are taking too much sugar). When the unborn child is fed with a lot of glucose, they end up producing a lot of insulin and there is a risk of going into low-blood sugar (hypoglycaemia) in the first few hours at birth because they are not getting the same amount of sugar as they were during gestation,” says Dama.
On the contrary, mothers don’t need that much extra food during the first trimester. From the 2nd trimester, they only need an extra 350 kilocalories, and they can get that from a cup of porridge. In the third trimester, they need an additional 500 kilocalories. Essentially, food intake should be increased gradually since the foetus grows gradually too.
Dama also points out that a lot of women are turning to online sources for information and some of the blogs, social media pages and even online personalities can be misleading. “Some patients ask questions when they already have answers from online and when you tell them something different, they counter your response with what they read on Google. Before researching online, bear in mind that we are all different, and the posts online are not tailored specifically for each one of us.”
Self-medication is also a common issue nowadays which often leads to complications. Dama notes that most self-medication cases have to do with infections on the private parts like UTIs. “During pregnancy, the body is changing but sometimes infections have nothing to do with pregnancy. It’s always advisable to talk to a doctor if you notice unusual symptoms,” Unfortunately, a lot of women are turning to “Doctor Google” for answers, and they end up getting the wrong diagnosis and rushing to pharmacists to buy meds over the counter.
A tooth for each baby?
When it comes to nutrition, there is an urgent need to be more intentional with diet during pregnancy. The foetus relies on nutrients for optimal development and growth. These nutrients also have the power to prevent birth defects. “A good example of a neural tubal defect is Spina Bifida which is caused by a lack of folic acid. It’s critical to get your diet right and it’s not about eating more but rather eating right,” says Dama.
So, what exactly does your growing baby need and why? Dama says all the nutrients both macro and micro are important but there are critical ones which should be optimised. Folic Acid (folate), Iron, Calcium, Protein, Vitamin D, Iodin, Vitamin A, Vitamin C, Vitamin B6 and Vitamin B12 are at the top of the list and there are good reasons. Folic acid, for instance, ensures that the nervous system develops well, while iron ensures the foetus has a sufficient blood supply. “People imagine that the foetus gets blood from the mother, but it produces its own”
Calcium and Vitamin D are for bone and teeth development while iodin helps in brain development. Vitamin A is what the foetus needs for healthy skin and eyesight. Vitamin C is for healthy gums and teeth. Vitamin B6 is used in the formation of red blood cells, and it helps to utilise proteins, fats and carbohydrates. Vitamin B12 maintains the nervous system. When a mother has deficiency in a nutrient, the foetus will get what it needs but the mother suffers.
A common phenomenon that demonstrates how this works is seen in women who lose teeth during pregnancy. It simply means they have low calcium levels but since the foetus needs calcium to form its bones, they simply ‘take’ what they need, leaving the mother with a deficiency. Your body will always communicate when there is a deficiency. “Muscle cramping, for instance, can be caused by low calcium and magnesium levels while bleeding gums can be an indicator of Vitamin C deficiency”.
Cravings could also be a sign that your body is running low on a particular nutrient, though hormones could also be involved. “Scientifically, cravings are believed to be caused by nutrition deficiency and hormonal changes which lead to a heightened change of smell during pregnancy.
For example, if you have iron deficiency, you easily smell iron which is plenty in the soil. There is, however, a difference between regular cravings and Pica. Pica means craving unusual substances. It can be dangerous when you crave things like paraffin or petrol which are obviously harmful to your body and your baby. It’s highly advisable to ignore such. Bear in mind that cravings are influenced by the environment and the foods you are exposed to.
A pregnant woman who has lived in the village all her life may not crave for pizza. And that means nothing will happen to you if you don’t get what you crave. There is room for regulation if you are craving potentially harmful substances or foods full of empty calories. You could try healthier alternatives. If you want ice cream, for instance, you may supplement with dates which are equally sweet but nutritious.”
Deficiencies are also dealt with at the hospital through supplements. Perhaps you’ve wondered why you are asked to take supplements by your doctor. Well, Dama explains that research has shown that most women do not get enough folic acid and iron from their diet. “As far as the government is concerned, these should be given routinely to pregnant women. They will need the reserves, especially due to bleeding during birth. Some women may be given additional supplements like calcium and zinc depending on their deficiencies. Iodin is not very common and vitamin D shouldn’t be a problem in our country”.
Finally, in the same way, you prioritise some nutrients, there are foods that should be avoided too, in pregnancy. Dama cautions against taking raw meat as causes bacterial infections with symptoms that tend to be more pronounced during pregnancy. “Cook your meat, eggs, chicken and pork properly and avoid unpasteurised milk.
Excess caffeine is also unhealthy. At most, take one to two cups. More than that will probably cross the placenta barrier to the foetus. When it comes to alcohol, there is no safe amount in pregnancy. Excessive alcohol puts the baby at risk of facial deformities and intellectual disability. Of course, maintain high levels of hygiene when handling food,
To wind up on matters of nutrition, Dama advises women not to overthink their diet. It does not cost much to eat healthy. “You do not need a whole kilo of meat to get enough protein. A non-pregnant person only needs 70 grams for the whole day if you weigh 70kg (1 gram per kg of body weight). When you are pregnant you need 1.2 grams per kg body weight. If you cannot afford meat and chicken, an egg is enough. Cooked beans will also do. A meal as simple as githeri with carrots and cabbage on the side is packed with enough nutrients.”
Is your body ready for conception?
We also spoke to Dr Felix Oindi, a consultant Obstetrician and Gynaecologist at the Aga Khan University Hospital. His work revolves around helping women plan for delivery and we sought to understand whether a gynaecologist is a must during the pregnancy journey, plus what risk factors should women look out for.
“My work starts at preconception-before patients get pregnant. At this point, I will look out for conditions that could lead to a bad outcome in pregnancy. Before conception, your body should be in the best shape possible. And there are conditions that will compel doctors to discourage you from conception or recommend close monitoring due to the risks involved. For instance, if you have diabetes, you stand a high chance of miscarrying or the baby developing problems with their back.
There is a blood test called HBA1C and depending on the levels, you can be advised not to conceive. Conditions like lupus, which affect different organs, increase the chances of miscarriage. If you’ve had miscarriages before, erratic blood pressure, stillbirths, uterus surgeries or many Cesaerian Sections in the past, you are also in the risk category. There are other issues like advanced age (above 35-45) or very advanced (above 45), being overweight (above a BMI of 25) obesity or having a chronic condition that demands close monitoring.”
High risk vs low-risk pregnancies
Though some women choose to only work with a gynaecologist after conception, seeing one before helps you determine whether it is safe to conceive and whether your body is in the best shape. After conception, a gynae will still be part of the journey. They will recommend blood tests and scans to identify conditions that might put the baby at risk and correct them if they are there. They will also advise on situations to avoid- that might put the pregnancy at risk while looking out for danger signs along the way.
But whether to work with a gynaecologist or not depends on two things. First, the facility you visit for ante-natal care. Some hospitals will have obstetricians and gynaecologists whenever you need them while others only have them once or twice a week. Others do not have these specialists at all. Second, the type of pregnancy will also determine your needs and whether they can be addressed by a midwife alone.
Dr Oindi notes, “There are basically two types of pregnancies- low risk and high risk. Low-risk pregnancies can be handled by a midwife, but high-risk pregnancies require specialised care from a consultant gynaecologist. If a midwife identifies issues that require extra care, they can refer a consultant. There will be additional professionals such as a nutritionist or a physician. If a mother has a chronic condition that requires an extra specialist, they are sent to them. For instance, if they have mental issues, they will see a psychiatrist while a diabetes patient will need to see a physician”
It’s important to understand that a low-risk pregnancy can easily turn into high risk. You could develop conditions such as high blood pressure or even diabetes along the way. Whether a pregnancy begins as low or high risk, specialist care is highly recommended. If you’ve advanced in your pregnancy without any specialised care and you develop complications along the way, it is also acceptable to seek help at any point in your pregnancy.
The transition period during delivery when the baby comes out is critical and there is a need for keen monitoring. During the delivery process, you are likely to work with a midwife, some hospitals have a gynaecologist on call. Though low-risk pregnancies are likely to progress smoothly, Oindi says, there are a few factors that might need urgent intervention. If you notice the poor progression of labour, for instance, it is wise to consult a specialist.
“Ideally, the cervix is supposed to open gradually till 10 centimetres for the baby to pass and at the same time the baby’s head is supposed to be facing down. If this is not happening, and all interventions are not working, you might want to consult or consider emergency CS. Other emergency situations could involve the baby being in another position other than what is expected. The baby’s heartbeat is also monitored and if the pulse is too fast or too weak or then it could be a sign that the baby is tired. A stuck baby that won’t come out requires the intervention of a gynae”.
Some of these cases can be handled by other practitioners within the maternity ward, but if you have been consulting with a gynae, you may have them on call if you notice anything out of the ordinary.
About home births….
Notably, there is increasing curiosity and popularity around home births, we sought to know what Dr Oindi thinks about them. Are they safe? “Home births have their pros and cons. On the one hand, they are very comfortable. You can set up in your bedroom and have a midwife deliver your baby privately and comfortably. In a busy maternity ward, midwives have tens if not close to hundreds of mothers (in the busiest public hospitals) to deliver. Of course, some women will feel like it’s not a good experience.
However, in countries where home births work well, the healthcare system is advanced, and women can access emergency health services in case something goes wrong during a home birth. Unfortunately, when it comes to emergencies in pregnancies, mothers do not have hours to get to a doctor. And if they do get to a hospital, they will not get into surgery immediately, because there are procedures and what if you get to the hospital and the theatre is already in use?
There are situations when a baby needs to be out in fifteen minutes and it will obviously take much longer to get to the hospital, sign the paperwork and be served. Pregnancies are very volatile, things can change very fast,” he says adding that if you are going to choose a home birth, at least consider access to emergency care in case something goes wrong.
Another factor to consider is that women who’ve had difficult pregnancies or risk factors require screening before they go for a vaginal birth, especially at home. Home births at the moment are not very formalised, and you may not get the necessary screening. In the Kenyan context, they have been popular for a very short time, and we do not have statistics on the babies delivered this way. It’s still too early to say that home births are entirely safe.